Frances T. Sheehan

USING CINE PHASE CONTRAST MAGNETIC RESONANCE IMAGING TO NON-INVASIVELY STUDY IN VIVO KNEE DYNAMICS

We tested the accuracy and feasibility of using cine phase contrast magnetic resonance imaging (cine-PC MRI) to non-invasively measure three-dimensional, in vivo, skeletal velocity. Bone displacement was estimated by integrating the velocity measurements. Cine-PC MRI was originally developed to directly and non-invasively measure in vivo blood and heart velocity. Since no standard of reference exists for in vivo measurement of trabecular bone motion, a motion phantom (consisting of a series of paired gears that moved a sample box containing a human femoral bone sample) was built to assess the accuracy of tracking trabecular bone with cine-PC MRI. The in-plane, average absolute displacement errors were 0.55 +/- 0.38 and 0.36 +/- 0.27 mm in the x- and y-direction, respectively. Thus, estimates of bone position based on the integration of bone velocity measurements are affected little by the magnetic properties of bone [Majumdar and Genant (1995) Osteoporos International 5, 79-92]. The velocity profiles of the patella, femur and tibia were measured in five healthy subjects during leg extensions. Extension was resisted by a 34 N weight. Subjects maintained a consistent motion rate (35 +/- 0.5 cycles min(-1)) and motion artifacts were minimal. Our results indicate that patellar flexion lags knee flexion and the patella tilts laterally and then medially as the knee extends. We conclude cine-PC MRI is a promising technique for the non-invasive measurement of in vivo skeletal dynamics and, based on our previous work, muscular dynamics as well.

In Vivo Tracking of the Human Patella Using Cine Phase Contrast Magnetic Resonance Imaging

Improper patellar tracking is often considered to be the cause of patellar-femoral pain. Unfortunately, our knowledge of patellar-femoral-tibial (knee) joint kinematics is severely limited due to a lack of three-dimensional, noninvasive, in vivo measurement techniques. This study presents the first large-scale, dynamic, three-dimensional, noninvasive, in vivo study of nonimpaired knee joint kinematics during volitional leg extensions. Cine-phase contrast magnetic resonance imaging was used to measure the velocity profiles of the patella, femur, and tibia in 18 unimpaired knees during leg extensions, resisted by a 34 N weight. Bone displacements were calculated through integration and then converted into three-dimensional orientation angles. We found that the patella displaced laterally, superiorly, and anteriorly as the knee extended. Further, patellar flexion lagged knee flexion, patellar tilt was variable, and patellar rotation was fairly constant throughout extension.

Human patellar tendon strain. A noninvasive, in vivo study.

This study showed the assumption of patellar tendon inextensibility was not valid, and the strain in the patellar tendon was higher than previously reported for other human tendons. The in vivo three-dimensional velocity profiles for the patella, femur, and tibia were measured noninvasively in 18 healthy knees during a low load extensor task using cine phase contrast magnetic resonance imaging. These data were used to calculate patellar tendon elongation and strain. Average maximum strains of 6.6% were found for a low load extension task at relatively small knee angles.

Quantitative MR measures of three-dimensional patellar kinematics as a research and diagnostic tool.

PURPOSE A three-dimensional (3D) study of normal patellar-femoral-tibial (knee) joint kinematics was performed using Cine Phase Contrast Magnetic resonance imaging (Cine-PC MRI) to determine the utility of this technique as a diagnostic tool in defining alterations in patellar tracking. METHODS Cine-PC MRI was originally developed to measure heart motion and blood flow and has now been adapted to the study of the musculoskeletal system. Thus, for the first time knee joint kinematics can be studied three-dimensionally, noninvasively, and in vivo during dynamic volitional leg extensions under load. Cine-PC MRI provides one anatomic and three orthogonal velocity images (vx, vy, and vz) for each time frame within the motion cycle. Bone displacements are calculated using integration and are then converted into both 3D orientation angles and 2D clinical angles. RESULTS The 3D patellar tilt and 2D clinical patellar tilt angle were nearly identical, even though these two angles have distinct mathematical definitions. The precision of the 2D clinical patellar tilt angle (N = 3) was approximately 2.4 degrees. CONCLUSIONS Since the overall subject (N = 18) variability for clinical patellar tilt angle and medial/lateral patellar displacement was low (SD = 2.9 degrees and 3.3 mm, respectively), Cine-PC MRI could prove to be a valuable tool in studying subtle changes in patellar tracking.

Limb positioning is critical for defining patellofemoral alignment and femoral shape

The source of patellofemoral pain is a common orthopaedic complaint that often is difficult to determine because of the lack of correlation between symptoms and specific clinical measurements. Excessive joint contact stresses resulting from patellofemoral malalignment and pathologic femoral shape often are associated with this pain. These measures are likely sensitive to the limb position (orientation and position relative to the imaging system with which they are quantified). Because of this sensitivity, the measures have large variations and do not show correlations with subjective symptoms. The purpose of this study was to determine if varying limb position resulted in significant changes in standard clinical measures of patellofemoral alignment and femoral shape. This dependence was investigated by simulating alterations in limb position through resectioning of three-dimensional magnetic resonance image sets (20 healthy knees) to create axial images with altered orientation (eight images) or location (four images) relative to a fixed reference. By quantifying the variability of the clinical measures across all images, it was determined that simulated alterations in limb position produced greater variability in femoral shape and patellofemoral alignment measures than the variability seen across control subjects. This indicated that a standardized method for establishing limb position relative to the imager is warranted.

A methodology to accurately quantify patellofemoral cartilage contact kinematics by combining 3D image shape registration and cine-PC MRI velocity data

Patellofemoral osteoarthritis and its potential precursor patellofemoral pain syndrome (PFPS) are common, costly, and debilitating diseases. PFPS has been shown to be associated with altered patellofemoral joint mechanics; however, an actual variation in joint contact stresses has not been established due to challenges in accurately quantifying in vivo contact kinematics (area and location). This study developed and validated a method for tracking dynamic, in vivo cartilage contact kinematics by combining three magnetic resonance imaging (MRI) techniques, cine-phase contrast (CPC), multi-plane cine (MPC), and 3D high-resolution static imaging. CPC and MPC data were acquired from 12 healthy volunteers while they actively extended/flexed their knee within the MRI scanner. Since no gold standard exists for the quantification of in vivo dynamic cartilage contact kinematics, the accuracy of tracking a single point (patellar origin relative to the femur) represented the accuracy of tracking the kinematics of an entire surface. The accuracy was determined by the average absolute error between the PF kinematics derived through registration of MPC images to a static model and those derived through integration of the CPC velocity data. The accuracy ranged from 0.47 mm to 0.77 mm for the patella and femur and from 0.68 mm to 0.86 mm for the patellofemoral joint. For purely quantifying joint kinematics, CPC remains an analytically simpler and more accurate (accuracy <0.33 mm) technique. However, for application requiring the tracking of an entire surface, such as quantifying cartilage contact kinematics, this combined imaging approach produces accurate results with minimal operator intervention.

The effective quadriceps and patellar tendon moment arms relative to the tibiofemoral finite helical axis.

The moment arm is a crucial parameter for understanding musculoskeletal dynamics as it defines how linear muscle force is transformed into a moment. Yet, for the quadriceps tendon this parameter cannot be directly calculated, as the patella creates a dynamic fulcrum. Thus, the effective quadriceps moment arm (EQma) was developed to define the quadriceps force to tibial moment relationship. In vivo data in regards to the EQma are lacking and the critical question of how patellofemoral kinematics may influence the EQma remains unresolved. Therefore, the purpose of this study was to quantify the in vivo EQma during a knee extension exercise in asymptomatic controls and to correlate the EQma with sagittal plane patellofemoral kinematics. While subjects (30F/10M, 26.5±5.6 years, 167.5±10.2 cm, 62.6±10.7 kg) cyclically flexed-extended their knees within the MR scanner, dynamic cine-phase contrast and cine MR images were acquired. From these data, patellofemoral kinematics, the ratio of the patellar tendon to quadriceps force, the patellar tendon moment arm, and the EQma were quantified. The EQma trended upwards (32.9-45.5 mm (females) and 31.5-47.1 mm (males)) as the knee angle decreased (50-10°). The quadriceps had a mechanical advantage (ratio of patellar to quadriceps tendon forces >1.0) for knee angles ≤20°. The EQma did not correlate with sagittal plane patellofemoral kinematics. As this is the first study to characterize the EQma in vivo during dynamic volitional activity, in a large group of asymptomatic controls, it can serve as a foundation for future knee joint models and to explore how pathological conditions affect the EQma.

Patellar Maltracking Persists in Adolescent Females With Patellofemoral Pain: A Longitudinal Study

Background: Patellofemoral pain is one of the most common conditions seen in sports medicine practices, particularly among adolescent females. However, the natural history of the underlying pathology in patellofemoral pain during puberty remains poorly understood. Purpose: The purpose of this longitudinal study is to assess changes in patellar maltracking patterns in subjects with patellofemoral pain as they mature from mid- to late adolescence. Study Design: Cohort study; Level of evidence, 3. Methods: Three-dimensional patellofemoral kinematic data were acquired during active knee extension-flexion using dynamic magnetic resonance imaging in 6 girls (10 knees; mean age, 14.0 years) with clinically diagnosed patellofemoral pain. The subjects then returned as late adolescents (mean age, 18.5 years) for follow-up scanning. Three-dimensional patellofemoral kinematic parameters were evaluated across the range of motion, but comparison between time points was restricted to 10° of flexion. Participation in impact and nonimpact physical activities, pain score based on the visual analog scale, and the anterior knee pain score were also compared across initial and follow-up visits. Results: All subjects reported improved patellofemoral pain symptoms at follow-up, and one subject reported complete resolution. However, relative to the initial visit, no differences were found in patellar maltracking. There was a decrease in hours engaged in impact physical activities for all subjects at follow-up. Conclusion: This study provides insight into the natural history of patellofemoral pain in adolescent females. The relatively unchanged patellofemoral maltracking across subjects suggests that potential anatomic and kinematic abnormalities contributing to patellofemoral pain during mid-adolescence persist during skeletal maturation. Symptom improvement for these subjects did not result from a change in patellofemoral tracking, but rather from other causes.

The Relationship of Static Tibial Tubercle–Trochlear Groove Measurement and Dynamic Patellar Tracking:

Background: The tibial tubercle to trochlear groove (TT-TG) distance is used for screening patients with a variety of patellofemoral joint disorders to determine who may benefit from patellar medialization using a tibial tubercle osteotomy. Clinically, the TT-TG distance is predominately based on static imaging with the knee in full extension; however, the predictive ability of this measure for dynamic patellar tracking patterns is unknown. Purpose: To determine whether the static TT-TG distance can predict dynamic lateral displacement of the patella. Study Design: Cohort study (Diagnosis); Level of evidence, 2. Methods: The static TT-TG distance was measured at full extension for 70 skeletally mature subjects with (n = 32) and without (n = 38) patellofemoral pain. The dynamic patellar tracking patterns were assessed from approximately 45° to 0° of knee flexion by use of dynamic cine-phase contrast magnetic resonance imaging. For each subject, the value of dynamic lateral tracking corresponding to the exact knee angle measured in the static images for that subject was identified. Linear regression analysis determined the predictive ability of static TT-TG distance for dynamic patellar lateral displacement for each cohort. Results: The static TT-TG distance measured with the knee in full extension cannot accurately predict dynamic lateral displacement of the patella. There was weak predictive ability among subjects with patellofemoral pain (r2 = 0.18, P = .02) and no predictive capability among controls. Among subjects with patellofemoral pain and static TT-TG distances 15 mm or more, 8 of 13 subjects (62%) demonstrated neutral or medial patellar tracking patterns. Conclusion: The static TT-TG distance cannot accurately predict dynamic lateral displacement of the patella. A large percentage of patients with patellofemoral pain and pathologically large TT-TG distances may have neutral to medial maltracking patterns.

Adolescents and Adults with Patellofemoral Pain Have Different Pathological Knee Kinematics

Disclosures: Liza Grosman-Rimon: I Have No Relevant Financial Relationships To Disclose Objective: The aims of the present study were to compare levels of circulating inflammatory biomarkers and growth factors between patients with myofascial pain syndrome (MPS) and control participants, and to assess the relationship among inflammatory markers and growth factors in the two groups. Design: Case-control. Setting: Patients recruited from the hospital Emergency Department and non-MPS controls (n1⁄421), recruited via advertisements in the hospital and community. Participants: Patients (n1⁄437) with myofascial pain and non-MPS controls (n1⁄421), recruited via advertisements in the hospital and community. Interventions: Venous blood draw for biomarker assessment. Main Outcome Measures: Serum inflammatory and growth factor. Results: Blood levels of the cytokines IL-6, TNF and IL-12 and the chemokines MCP-1, MDC, eotaxin, GM-CSF, IL-8, MIP-1b were significantly higher in patients with MPS than controls. The results of the growth factor analyses revealed significantly higher levels of FGF-2, PDGF, and VEGF in MPS patients versus controls. The pattern of correlation coefficients between cytokines and growth factors differed considerably for MPS patients and controls with far fewer significant coefficients observed in the controls. Serum inflammatory and growth factor biomarkers were elevated in MPS patients. Conclusions: Inflammatory biomarkers and growth factor levels may play an important role in the onset and maintenance of MPS and therefore may be useful in the diagnosis and treatment of MPS. Understanding the mechanisms of inflammation in MPS necessitates future research. Level of Evidence: Level III